Chilaiditi sign is defined by hepatophrenic intestinal interposition. When it is associated to pain, it is called Chilaiditi syndrome; commonly, incidentally discovered, and/or secondary to a complication like intestinal occlusion and bowel ischemia. We describe the case of a patient who was admitted to our radiology department to release a body-computed tomography (CT) for its breast cancer extension assessment, we incidentally discovered a colic hepato-phrenic interposition related to a Chilaiditi sign associated with right renal agenesis.

A 66-year-old female with a newly diagnosed breast carcinoma presented with right upper quadrant pain and sensation of heaviness.

Investigations

A contrast-enhanced CT of thoracic, abdomen, and pelvis was performed with series obtained in portal phase for initial extension assessment and to explore the symptomatology. It demonstrates an interposition of transverse colon between liver and diaphragm (Figure 1). Besides CT also shows a right empty renal fossa with left normal kidney and no other anomalies were noted, related to a renal agenesis (Figure 2).

 Differential diagnosis

In front of the medical history of breast carcinoma the diagnosis of an interposed intestine between the diaphragm and the liver can be mistaken with a peritoneal node, especially when it is empty. Pneumoperitoneum can be another misleading diagnosis in a traumatic context. Finally, a perihepatic abscess can mimic it.

Treatment

No intervention is required for an asymptomatic patient with Chilaiditi sign. Those with abdominal pain or distension are usually treated conservatively with analgesia and fluid resuscitation. Patients with recurrent presentations or evidence of bowel ischemia may be offered surgical treatment.

Chilaiditi syndrome is used to describe pain caused by an interposition of the intestine between liver and diaphragm, which is called Chilaiditi sign. Firstly, described in 1910, it is named after a Greek radiologist Chilaiditi Demetrius [1].

It is an uncommon syndrome, occurring its incidence varies from 0.25% to 0.28% of the general population and affects mainly male and elderly patients [2], [3].

Different predisposing factors engender the development of Chilaiditi sign [4]. Its cause still remains unknown, but it is probably multifactorial. Congenital anatomical abnormalities such as colonic elongation and laxity of colonic and hepatic suspensory ligaments have been postulated as the principal predisposing factors. Other predisposing situations can be acquired such as an enlarged lower thoracic outlet (e.g., pregnancy, emphysema, and cirrhosis with ascites), or organ shrinkage (atrophic cirrhosis of the liver). Fat deposition between the liver and the colon, in obese individuals, widens the space between the two organs and can also favor the migration of the colon [5].

It is usually asymptomatic and mostly discovered incidentally on CT examination. Most frequent symptoms are abdominal pain, nausea, vomiting, and respiratory distress. Differential diagnoses of this radiographic sign include pneumoperitoneum, peritoneal nodes, and subphrenic abscess. Main complications are intestinal occlusion and bowel ischemia [6]. Chilaiditi syndrome has been associated with a variety of pulmonary or gastrointestinal malignancies (involving the colon, rectum, or stomach) [7].

If Chilaiditi sign is visualized and the patient is symptomatic, it is then referred to as Chilaiditi’s syndrome. Gastrointestinal symptoms, such as epigastric pain, nausea, vomiting, constipation, abdominal distention are the main symptoms [6].

Diagnosis of the disease is made primarily through CT scans. It demonstrates the air below the diaphragm associated with visible intestinal haustra, which does not change with variation in patient position. Besides, elevated right hemidiaphragm above the liver by the intestine and depression of the superior margin of the liver below the left hemidiaphragm are associated. The differential diagnoses of Chilaiditi syndrome can include diaphragmatic hernia, pneumoperitoneum, and subphrenic abscess [7].

Complications of Chilaiditi syndrome may include a volvulus of the cecum, splenic flexure, or transverse colon. Cecal perforation and, rarely, perforated subdiaphragmatic appendicitis can also occur as complications of Chilaiditi syndrome [8]. Respiratory distress, cardiac arrhythmia and serious complications, can also be seen [9].

In this case report we treated Chilaiditi sign can exist without Chilaiditi syndrome, as it could be associated with other pathologies and abnormal anatomic malformation like renal agenesis. Radiologic investigation is crucial to stand up the right diagnosis, the radiologist has to pay attention to not confuse it with other differential diagnosis, mainly with pneumoperitoneum and peritoneal nodes for patients with malignancies.